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research-article2013
CNU13610.1177/1474515113514864European Journal of Cardiovascular NursingAstin et al.
EUROPEAN SOCIETY OF CARDIOLOGY ®
Original Article
European Journal of Cardiovascular Nursing 2014, Vol. 13(6) 532–540 © The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1474515113514864 cnu.sagepub.com
Education for nurses working in cardiovascular care: A European survey The Working Group of the Education Committee of the ESC Council on Cardiovascular Nursing and Allied Professions Authors/Working Group Members: Felicity Astin1, Diane L Carroll2, Sabina De Geest3, and Jan Martensson4
Contributors/Working Group Members: Ian Jones (UK), Lynne Hunterbuchner (Austria), Catriona Jennings (UK), Eleni Kletsiou (Greece), Agnieska Serafin (Poland), and Fiona Timmins (Republic of Ireland) Abstract Background: Nurses represent the largest sector of the workforce caring for people with cardiovascular disease in Europe. Little is known about the post-registration education provided to nurses working within this specialty. The aim of this descriptive cross sectional survey was to describe the structure, content, teaching, learning, assessment and evaluation methods used in post-registration cardiovascular nurse education programmes in Europe. Method: A 24-item researcher generated electronic questionnaire was sent to nurse representatives from 23 European countries. Items included questions about cardiovascular registered nurse education programmes. Results: Forty-nine respondents from 17 European countries completed questionnaires. Respondents were typically female (74%) and educated at Masters (50%) or doctoral (39%) level. Fifty-one percent of the cardiovascular nursing education programmes were offered by universities either at bachelor or masters level. The most frequently reported programme content included cardiac arrhythmias (93%), heart failure (85%) and ischaemic heart disease (83%).The most common teaching mode was face-to-face lectures (85%) and/or seminars (77%). A variety of assessment methods were used with an exam or knowledge test being the most frequent. Programme evaluation was typically conducted through student feedback (95%). Conclusion: There is variability in the content, teaching, learning and evaluation methods in post-registration cardiovascular nurse education programmes in Europe. Cardiovascular nurse education would be strengthened with a stronger focus upon content that reflects current health challenges faced in Europe. A broader view of cardiovascular disease to include stroke and peripheral vascular disease is recommended with greater emphasis on prevention, rehabilitation and the impact of health inequalities. Keywords Cardiovascular nursing, curriculum, post-registration nurse education programmes, survey, questionnaire Received: 22 April 2013; revised: 7 November 2013; accepted: 10 November 2013
1School
of Nursing, Midwifery, Social Work and Social Sciences, University of Salford, Manchester, UK 2Yvonne L. Munn Centre for Nursing Research, Massachusetts General Hosital, Boston MA, USA 3Centre for Health Services and Nursing Research, Kathlieke Universiteit Leuven, Belgium
4School
of Health Sciences, Jonkoping University, Sweden
Corresponding Author: Felicity Astin, School of Nursing, Midwifery & Social Work, Mary Seacole Building, (Room 1.64), University of Salford, Salford, M6 6PU, UK. Email: [email protected]
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Introduction Cardiovascular disease (CVD) including stroke, ischaemic heart disease (IHD) and heart failure (HF), represents a significant global health burden responsible for 47% of deaths in Europe alone.1 The greatest health challenge we face today is the epidemic of lifestyle-related conditions such as obesity and diabetes, combined with the ageing of the population. Although CVD mortality has fallen in most European countries an increase in cigarette smoking and physical inactivity, particularly amongst women and girls, is of concern.1 Non-communicable diseases will dominate with CVD and depression being the leading causes of healthy life years lost.2 An increasing number of people will live with one, or more, long-term conditions, making their care needs increasingly complex. The aging of the population means that the type of care required by people will be complex, continuous and community-based. The focus will require a paradigm shift from one of ‘cure’ to ‘care’. To tackle these health challenges health care workers, health care organisations and health care systems need to improve effective management of CVD within a long-term condition paradigm, with major efforts to be invested not only in state of the art medical therapy, but in primary and secondary prevention through collaborative partnerships with patients and their families. Nurses play a central role in cardiovascular (CV) care and optimum educational preparation and continuing education and professional development should guarantee that this, largest group of health care professionals, have the knowledge, skills and attitudes needed to contribute to reducing the burden of CVD .3 The Munich declaration: Nurses and midwives: A force for health published in 2000 marked an important turning point in the visibility of nurse and midwives in the European healthcare workforce.4 The document formally recognised the importance of nurses and midwives as a significant workforce with the capacity to make a considerable contribution to tackling the emergent public health challenges in Europe. Ministers of Health, the World Health Organisation (WHO) Regional Office for Europe and national nursing and midwifery associations unanimously supported the declaration. To fully realise the contribution of nurses it was acknowledged that initial and continuing education for nurses required strengthening. Moreover, legislative and regulatory frameworks needed to be in place to support comprehensive workforce planning and enable nurses to work as independent and interdependent professionals within their countries. In fact, the nature of the legislative and regulatory frameworks shapes educational provision and determines which clinical roles (e.g. advanced practice nurses’ roles) CV nurses are prepared for and their scope of practice within each role. A series of surveys was conducted to monitor and evaluate the implementation of the Munich declaration: findings from the 2009 survey indicated that reform of legislative frameworks for nursing had occurred in some
countries leading to an expanded scope of practice and responsibility.5 Moreover, the transition of nursing education from clinical settings to the higher education sector had also supported the establishment of self-regulatory bodies for nursing in some countries. Despite this progress, huge diversity in nursing preparation and practice remains largely unchanged across countries in the European region.6 This diversity is reflected in the educational preparation of nurses working in CV care across Europe. Preliminary evidence tells us that there is considerable variation in the setting in which educational provision takes place, whether it be university or non-university based. Moreover, there is considerable variety in the learning content and the scope of role expectations following basic nursing education throughout Europe.3 While there is an evolution towards a clearly articulated level of educational achievement for nurses from bachelor, master through to doctoral level (i.e. Bologna declaration7), as well as an investment in the streamlining of the educational structures and content within the European Union through the European Qualifications Framework,8 a wide spectrum of post-registration educational provision remains ranging from short programmes aimed at continuing education, to more advanced provision with accreditation to equip nurses for clinical specialist and advanced practice roles. Improved education, training and career development of nurses has been identified as a priority area to strengthen future nursing and midwifery services according to the WHO Nursing and midwifery services strategic directions, 2011–2015.9 Despite improved education being identified as a priority for nurses and midwives in Europe little is known about current post-registration programme provision. It is unclear how many programmes exist and the key features of the curricula and how they are evaluated. The aim of this study was to establish the number of CV education programmes that exist in Europe and to identify how they are structured, delivered and evaluated, the scope of content delivered and preferred assessment approaches.
Methods Definition For the purposes of this study a CV nursing programme was defined as the structured, provision of a CV education programme regardless of the type of programme, delivery methods used, and programme duration. Design. This descriptive study used a cross-sectional survey design with the administration of an electronic researcher-developed questionnaire. Sample and setting. A staged sampling approach was used to recruit participants. In the first stage, members of the Education Committee of the Council of Cardiovascular Nursing
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Table 1. Geographical distribution of countries involved in the survey. Country
Number of completed questionnaires by country (a)
United Kingdom/Ireland Sweden Czech Republic Austria, Iceland Greece, Poland Belgium, Bulgaria, Croatia, Cyprus, Finland, Germany, Lithuania, Portugal, Switzerland Total of participating countries=17
17 (1) 8 (3) 6 5 (1 Austria, 1 Iceland) 2 (1 Greece, 1 Poland) 9
aThe
41 (8)
number in brackets is of institutions reported not to have a course in which cardiovascular nursing was considered part of the curriculum.
and Allied Professional (CCNAP) identified nurse representatives from 43 European countries through existing national society networks. Nurse representatives, from 23 of the 43 European countries, were successfully identified and agreed to support recruitment. In the second stage, nurse representatives were asked to identify all CV nursing programmes in their country and to invite one person per CV nursing programme to complete the electronic questionnaire. Participants could respond if their organisation provided either a module/unit about CV nursing or a full programme that nurses could take after their initial training. Questionnaire development. A review of the literature identified no validated survey questionnaires developed to describe CV nurse education that we could adapt for our use. Accordingly the CCNAP Education Committee developed a 30-item questionnaire with two open and 28 closed questions. The survey questionnaire was informed by three key documents concerning educational provision for health professionals caring for people living with long-term conditions, and CV nurse education in particular. These were: the 2005 WHO report on basic competencies for the healthcare workforce in the 21st century in view of long-term conditions;10 the American Nurses Association and the American College of Cardiology Foundation, Cardiovascular nursing: Scope and standards of practice11; and the ‘European nurse training programme for clinical expertise in heart failure’ developed by the HF Association and CCNAP.12 The WHO report (2005) identifies patient-centred care, partnering, quality improvement, communication/information technology and a public health perspective as the basic competencies required by a 21st century healthcare workforce.10 The American Nurses Association and the American College of Cardiology Foundation Cardiovascular nursing: Scope and standards of practice11 document defines competencies beyond basic nursing education that link to both clinical practice and professional performance. Clinical practice competencies refer to assessment and management of CV conditions, education and counselling skills for comprehensive risk factor reduction, disease management and motivating patients to engage with a healthy lifestyle. Professional performance
competencies refer to research and evaluation skills, collaborative working, ethical practice and leadership. The European Society of Cardiology (ESC) ‘European nursing training programme for clinical expertise in heart failure’12 was also referred to as it referred to many of the aforementioned competencies and highlights the skills required to set up and run a heart failure programme. The survey questionnaire was developed and reviewed by the CCNAP Education Committee membership and two independent experts to establish face validity and completeness for the different countries in which data collection would take place. The tool was piloted on five expert nurse educators from Sweden (two), UK (two) and Switzerland (one). Minor amendments were made to reflect suggestions and a glossary of terms produced to promote equivalence in the understanding of terms across countries. The final version of the questionnaire addressed five areas: participant demographics and the reported need for a postregistration CV course (15 items); programme characteristics (10 items); teaching and learning methods (two items); assessment strategies (two items); and programme evaluation (one item). Items that defined the programme characteristics were divided into eight objectives. For each item the respondent was asked to confirm that specific topics were a part of their CV nursing programme as either ‘yes’ or ‘no’. The last item invited participants to comment on the value of a post-registration education programme developed by CCNAP. Appendix 1 in the Supplementary Material shows an abridged version of the questionnaire. Data collection procedures. The survey was conducted from December 2009–August 2011. The questionnaire and a covering letter explaining purpose, procedures, the need for only one survey per programme, and a web link to the survey was sent to the key contact persons who then further distributed these items among institutions and organisations that offered CV educational programmes.
Data analysis Data was transposed from the electronic questionnaire to esMaker, a web-based digital survey and analysis tool.13
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Astin et al. The items on the survey were individually analysed using descriptive statistics, i.e. frequencies and percentages of responses to each individual item.
Results Sample characteristics Of the 43 countries targeted to complete the survey, we identified key contact persons in 23 countries (57.5%). The key contact persons were identified either through the National Cardiology Society or known personal contacts of the CCNAP Education Committee membership. From these 23 European countries with contact persons, we had 17 countries that had 49 separate organisations that provided responses to the survey for individual postregistration programmes, providing a response rate at the country level of 41% (Table 1). Five organisations had more than one post-registration programme that met the inclusion criteria for our survey and therefore completed a survey for each. Participant demographics. The majority of the respondents who completed a survey, were female (74%) and were educated at the master (50%) or doctoral (39%) level. The role of the respondents in their respective organisations was lecturer/teacher (44%), senior lecturer (16%), head nurse (14%), project manager/director (10%), secretary/ administrator (8%), professor/associate professor (4%) or clinical lecturer (4%). Programme characteristics. Of the reported programmes, 68% were predominantly offered by a university, 20% by a hospital, 5% by a technical college and 5 (7%) by others such as district chambers, institutes for advanced training and national centre for nursing and health professions. Twenty-one programmes were reported (51%) to be part of an academic degree, both bachelor and master level, whilst 14 (34%) were certificates or diplomas offered by a variety of organisations. Four (7%) responses were from a part of a continuing education programme for post-registration nurses. Entry requirements were variable among programmes. For instance, 22 (54%) required clinical experience ranging from at least six months to five years, while 19 (46%) did not require any clinical experience. The European Credit Transfer System (ECTS) was used in 15 (37%) of the programmes. Course content. The next section describes findings about course content delivered across programmes. We present key findings in this article but all data can be accessed by readers in the accompanying electronic file (see Supplementary Material). In 27 (55%) of the programmes, CV nursing accounted for more than 50% of the programme content.
Objective 1: The scope of cardiovascular conditions taught to nurses. The CV conditions taught in more than 50% of nurse education programmes were cardiac arrhythmias, HF and IHD including angina and acute coronary syndrome, valvular heart disease, endocarditis, syncope and congenital heart disease. Less than half of programmes covered heart transplantation and peripheral vascular disease (PVD). Objective 2: The diagnosis of cardiovascular conditions. There was a range of content taught in nurse education programmes about diagnostics, both theory and skills. The process of recording and interpreting an electrocardiogram (ECG) was a key focus. Also biomarker interpretation, history taking and physical assessment were taught in more than half of the programmes. Assessment of heart and lung sounds and chest X-ray interpretation was taught in less than 50% of programmes. Objective 3: The impact of cardiovascular conditions on mortality and morbidity. In relation to the impact of CV conditions on mortality and morbidity rates, most programmes focused upon HF, IHD, valvular heart disease and arrhythmias. Content about congenital heart disease and PVD was less frequently addressed Objective 4: Supporting best practice in pharmacological treatments. CV medication guidelines were discussed in most of the programmes including detail about the mode of action and side effects of medications. Specific content on pharmacological treatment linked to cardiac interventions was most commonly reported for arrhythmia procedures, HF and IHD. Over half of the programmes addressed medication adherence with few programmes discussing valvular and congenital heart disease medications, or the impact of genetic variants on medication options. Objective 5: Nursing care and management of people with cardiovascular disease. Nursing care was most often discussed in relation to arrhythmia control procedures including device implantation and percutaneous coronary interventions and least often discussed in relation to congenital repairs. Content related to the management of healthy heart lifestyle behaviours was included in the majority of programmes (see Figure 1). Content related to sleep hygiene and complementary therapies was included in less than 50% of programmes. Objective 6: Using educational and behavioural theory to inform practice. More than 60% of the programmes identified theories linked to either student learning (for example adult learning theory) and/or behavioural theory (for example social cognition theory) to support practices such as patient education. More than half of the programmes taught students about ways to assess patients and families’ readiness
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Arrhythmia control procedures (Pacemaker, ICD) Percutaneous coronary interventions Coronary artery surgery Heart valve repairs and replacement Aortic repairs and replacement Heart transplantation Peripheral endovascular interventions Congenital repairs None 0
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Figure 1. Educational content taught about nursing care and management in post-registration nursing programmes (n=41). ICD: Implantable Cardiac Defibrillator.
Patient centred care Assessment of patient and family psychosocial needs Involving family and significant others Use of screening tools for anxiety and depression Human responses to CVD diagnosis and disease Identification of coping and crisis responses Cultural competence Accessing information in the community Therapeutic counselling techniques Identification of changes across the lifespan None 0
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Figure 2. Psychosocial activities taught in post-registration nursing programmes (n=41).
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Communication with patients and families Patient advocacy and patient centered care Defining the role of the members of the team Read and critique research for evidence-based care Use code of ethics for nursing Implement evidence-based clinical practice change Quality improvement inititiaves None 0
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Figure 3. Educational activities about multidisciplinary team building taught in post-registration nursing programmes (n=41).
to learn, barriers to learning, and how to define and evaluate learning outcomes. Almost one-fifth of the programmes reported that they did not teach any educational theory. Objective 7: Psychosocial assessment and support. Most programmes taught patient-centred care, psychosocial assessment and the principle of involvement of patients and family. Just over half of the surveyed programmes included content about screening for negative mood states (anxiety and depression)., Therapeutic counselling techniques, community, lifespan and cultural competences were available in less than 50% of programmes. See Figure 2. Objective 8: Promoting multidisciplinary team work. Content related to multidisciplinary team work were included in the majority of the programmes (Figure 3). The most frequently reported activities centred on effective communication skills, patient advocacy and the definition of the roles of multidisciplinary team members. Teaching and learning methods. The most widely used teaching and learning strategies in surveyed programmes were face-to-face lectures and seminars. Face-to-face lectures and seminars (when students present topics to other students followed by a discussion) were ranked as the most commonly reported educational delivery methods used in 97%, and 85%, of programmes respectively. The predominant framework used to assess the competency levels for the education programmes was most often based on a country-defined assessment (48%), or a skill
checklist (35%). Fifteen (37%) programmes were linked to ECTS with allocated points varying from 7.5–180. Other programmes had implemented alternative credit systems whilst others were unsure of what was offered for credit Assessment approaches. A variety of methods were used to assess knowledge and skill competency but examinations/ knowledge tests were the most frequently used techniques followed by essays and case studies. Other less commonly used assessment approaches were observed structured clinical assessment, portfolio, self assessment or peer review. Two programmes did not report an assessment approach for students. Course evaluation. Programme evaluation was most frequently conducted by students (n=39, 95%), educators (n=24, 58%), hospitals/universities (16, 39%), and external reviewers (n=18, 44%). All respondents reported an interest in the development of a post-registration programme in CV nursing should it be available.
Discussion Nurses are recognised as a significant workforce and have the potential to contribute to the vision of the ESC which is to reduce the burden of CVD. A snapshot of current educational provision gives a useful insight into the capability of the European nursing workforce. In 2009 less than half of the initial nurse education was provided by higher education institutions.5 This suggests that organisations providing
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vocational education were somewhat underrepresented in our sample as over 70% of participants were employed by a university. However, despite this higher than average representation from higher education institutions, only half of the programmes identified offered graduate or postgraduate level education. This finding highlights that a large proportion of nurse education continues to be delivered at a relatively low academic level when compared to other healthcare disciplines. When exploring the content of the curricula it was evident that the educational focus was based predominantly upon the management of patients with coronary heart disease (CHD) with less focus on the needs of patients with other forms of CV disease. The focus on CHD seems logical as it remains the leading cause of death across Europe, except in Greece, the former Yugoslav Republic of Macedonia, and Portugal where stroke takes the lead,1 but it would be advisable to take a wider view of the impact of CVD on health. Not all of the diagnostic procedures received the same attention in CV educational programmes. ECG interpretation was included by almost three-quarters of participating organisations whereas other aspects of physical assessment such as cardiac and respiratory auscultation and chest X-ray interpretation received less focus. This may reflect the extended scope of nursing practice evident in some countries compared to others. The assessed curricula included general information on pharmacological management of CV patients, yet only half of all programmes have integrated content of medication adherence which is a limitation given that nurses are in an excellent position to support patients with the management and adherence of prescribed medicines. This is particularly important given that medication adherence is a significant problem. Medicines will only work if they are taken and less than half of patients adhere to their recommended regime.14 Other aspects of self-management support and lifestyle change were better represented but the theories and interventions linked to patient education and behavioural change strategies were less well covered than the specific health behaviours. This suggests that there is a focus upon what lifestyle behaviours should be ‘changed’ rather than an emphasis on how interventions can be used to facilitate change. Nurses can make a significant contribution towards reducing the burden of CHD through their contribution, as a member of the multidisciplinary team, in the implementation of secondary prevention guidelines in clinical practice.15 To do this they need to be equipped with a basic understanding of educational and behavioural theory. The lack of emphasis on this content within the curriculum was surprising as competencies around effective communication, information provision and education of patients and families form the cornerstone of preventive cardiology in practice. These aspects of nursing curricula warrant attention. Self-management support to foster a healthy lifestyle for people diagnosed with CVD is an
essential competency for health care workers in the 21st century.10 The importance of patient-centred care was reflected in curricula, as was the assessment of psychosocial needs and family involvement. Other areas such as screening for negative mood states, culturally competent care, counselling skills and material describing normal and abnormal coping responses were less evident. Education about quality improvement initiatives was also fairly limited, meaning that an ability to demonstrate the provision of high quality care might be lacking. The way in which the content is delivered was typically through face-to-face lectures. The growth of educational technology will mean that more creative learning and teaching approaches will evolve and, where possible, methods that encourage nurses to engage with their learning and consider critical aspects of care should be considered. Likewise, most programmes used knowledge tests and examinations with other assessment methods, which are potentially more likely to assess understanding, somewhat underrepresented, e.g. supervisor’s report of clinical skill, portfolio and self-assessment. The WHO report argues that highly educated nurses are able to provide high quality care and ultimately reduce mortality (2009).3 Chan (2013) argues further that it is vital that we create and sustain a better-educated nursing workforce to meet the complex service needs of the future.16 If we are to achieve this aim it is necessary to increase the level of education of the nursing workforce whilst ensuring that learning and teaching methods produce competent, compassionate, knowledgeable, critical and reflective practitioners. In order to adopt a pan-European approach to the development of nurse education it may be necessary to extend the use of the ECTS points which is not yet common. A more widespread adoption of this initiative would support equivalence of awards across different institutions which would confer a range of benefits such as enhancing student mobility, aiding curriculum design and flexible routes to higher awards as well as supporting quality assurance processes.7,8 In summary, findings suggest that curricula for postregistration CV education are still largely driven by a medical model and characterised by traditional curricular structures and methods. Moreover, the emphasis on hospital care is stronger than on primary and community health care and competencies that would prepare nurses to care for the exponentially-growing group of patients that live with one or more chronic illnesses including CVD disease are given limited attention. A European core curriculum for post-registration CV education may be one approach towards harmonisation of nurse education across Europe but consensus must be reached about the characteristics of the core competencies and the feasibility of this approach across countries with diverse regulatory, educational and legislative frameworks.
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Astin et al. Whilst this study is one of the first published studies to assess CV nurse education in Europe it has several limitations which must be considered. There were considerable challenges linked to the sampling approach adopted. Given that no list of European postgraduate programmes exists, a staged sample approach was needed. A concerted effort was made to secure representation across all countries to minimise selection bias. We used key informants in the various European countries who subsequently identified and directed us to contacts who were knowledgeable about post-registration CV nurse education programmes in their respective countries. The failure to identify key informants in all European countries and/or the subsequent unsuccessful distribution of surveys within countries, partly because of language barriers as the survey was in English, resulted in a number of European countries not being included in the survey such as France, Italy, Spain, Norway, Romania, former Yugoslavia, Turkey and Hungary. The process was also time consuming which resulted in a delay between some data being collected and published. We acknowledge these limitations but, given the scarcity of information on this topic, we believe that our findings still warrant attention. We sought advice regarding common educational terms to support equivalence across different countries/languages but, despite this, some terms may not be accurately translated across educational settings.
Conclusion In conclusion, there is variability in the content, teaching, learning, assessment and evaluation methods in post-registration CV nurse education programmes in Europe. This reflects the variations in scope of nurse practice across different countries. CV nurse education would be strengthened with a stronger focus upon content that aligns more closely with current health challenges faced in Europe. A broader view of CVD to include stroke and PVD would be advantageous with an emphasis on prevention, rehabilitation and a greater awareness of the impact of health inequalities. As the population ages, teamworking across professions and specialties will be key as patients will be older and present with multiple co-morbidities requiring complex care and long-term support. An emphasis on interdisciplinary education will foster more effective teamwork across multidisciplinary teams and the use of advanced educational technology to deliver blended learning in a flexible way can afford many potential benefits.
Implications for practice • •
ducational provision for cardiovascular E nurses varies considerably across Europe. Access to graduate level education for nurses, the largest workforce in Europe, remains inconsistent.
• •
•
odernisation of nursing curricula should M include additional education on hypertension, stroke and peripheral vascular disease Additional education linked to lifestyle behaviour change is required with emphasis on prevention, rehabilitation and health inequalities. The use of educational technology may widen access to education for nurses.
Acknowledgements The authors would like to acknowledge the support of the ESC and national societies in supporting this study.
Conflicts of interest The authors declare that there are no conflicts of interest.
Funding This research was supported by funds from the European Society of Cardiology.
References 1. Institute for Health Metrics and Evaluation. The global burden of disease: Generating evidence, guiding policy. Seattle, WA: IHME, 2013. 2. US Department of Health and Human Services. Healthy 2020, http://www.healthypeople.gov/2020/ TopicsObjectives2020/pdfs/HP2020_brochure_with_ LHI_508.pdf (2010, accessed 27 November 2013). 3. World Health Organization. Global standards for the initial education of professional nurses and midwives, http://www. who.int/hrh/nursing_midwifery/hrh_global_standards_education.pdf (2009, accessed 15 April 2013). 4. World Health Organization. Munich declaration: Nurses and midwives: A force for health, http://www.euro.who. int/__data/assets/pdf_file/0007/53854/E93016.pdf (2000, accessed 15 April 2013). 5. Buscher A, Sivertsen B and White J. Nurses and midwives: A force for health, survey on the situation of nursing and midwifery in member states of the European region of the WHO, http://www.euro.who.int/__data/assets/ pdf_file/0019/114157/E93980.pdf (2009, accessed 27 November 2013). 6. Robinson S and Griffiths P. Nursing education and regulation: International profiles and perspectives. Nursing Research Unit, King’s College London, http://eprints.soton. ac.uk/348772/1/NurseEduProfiles.pdf (2007, accessed 15 April 2013). 7. Confederation of EU Rectors’ Conferences and the Association of European Universities. The Bologna Declaration on the European space for higher education: An explanation. http://ec.europa.eu/education/policies/educ/ bologna/bologna.pdf (2000, accessed 15 April 2013). 8. Lokhoff J, Wegewijs B, Durkin K, et al., of Nuffic/TUNING Association. Tuning educational structures in Europe, a
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European Journal of Cardiovascular Nursing 13(6) guide to formulating degree programme profiles, http://www. unideusto.org/tuningeu/ (2010, accessed 15 April 2013). Anderson DJ, Chan E, Dresner P, et al. Nursing and midwifery services strategic directions, 2011–2015, World Health Organization, Switzerland, http://www.who.int/heh/ nursing_midwifery/en/ (2010, accessed 15 April 2013). Pruitt SD and Epping-Jordan JE. Preparing the 21st century global healthcare workforce. Brit Med J 2005; 330; 637–639. American Nurses Association and the American College of Cardiology Foundation. Cardiovascular nursing: Scope and standards of practice. Silver Spring, Maryland: Nursebook. org, 2008. European Society of Cardiology. European nursing training programme for clinical expertise in heart failure, http://
www.escardio.org/communities/HFA/committees/hfmanagement/Pages/Training.aspx (accessed 10 February 2013). 13. Entergate. EsMaker – a web-based survey and analysis tool, http://www.entergate.se/ (2008, accessed 10 February 2011). 14. Lee WL, Abdullah KL, Bulgiba AM, et al. Prevalence and predictors of patient adherence to health recommendations after acute coronary syndrome: Data for targeted interventions? Eur J Cardiovasc Nurs 2013; 12: 512–520. 15. Mansoor SM, Krass I and Asiani P. Multiprofessional interventions to improve patient adherence to cardiovascular medications. J Cardiovasc Pharmacol Ther 2013; 18: 19–30. 16. Chan J. Nursing education makes a difference. Int J Nurs Pract 2013; 19: (Suppl. 1) 1–2.
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research-article2013
CNU13610.1177/1474515113514864European Journal of Cardiovascular NursingAstin et al.
EUROPEAN SOCIETY OF CARDIOLOGY ®
Original Article
European Journal of Cardiovascular Nursing 2014, Vol. 13(6) 532–540 © The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1474515113514864 cnu.sagepub.com
Education for nurses working in cardiovascular care: A European survey The Working Group of the Education Committee of the ESC Council on Cardiovascular Nursing and Allied Professions Authors/Working Group Members: Felicity Astin1, Diane L Carroll2, Sabina De Geest3, and Jan Martensson4
Contributors/Working Group Members: Ian Jones (UK), Lynne Hunterbuchner (Austria), Catriona Jennings (UK), Eleni Kletsiou (Greece), Agnieska Serafin (Poland), and Fiona Timmins (Republic of Ireland) Abstract Background: Nurses represent the largest sector of the workforce caring for people with cardiovascular disease in Europe. Little is known about the post-registration education provided to nurses working within this specialty. The aim of this descriptive cross sectional survey was to describe the structure, content, teaching, learning, assessment and evaluation methods used in post-registration cardiovascular nurse education programmes in Europe. Method: A 24-item researcher generated electronic questionnaire was sent to nurse representatives from 23 European countries. Items included questions about cardiovascular registered nurse education programmes. Results: Forty-nine respondents from 17 European countries completed questionnaires. Respondents were typically female (74%) and educated at Masters (50%) or doctoral (39%) level. Fifty-one percent of the cardiovascular nursing education programmes were offered by universities either at bachelor or masters level. The most frequently reported programme content included cardiac arrhythmias (93%), heart failure (85%) and ischaemic heart disease (83%).The most common teaching mode was face-to-face lectures (85%) and/or seminars (77%). A variety of assessment methods were used with an exam or knowledge test being the most frequent. Programme evaluation was typically conducted through student feedback (95%). Conclusion: There is variability in the content, teaching, learning and evaluation methods in post-registration cardiovascular nurse education programmes in Europe. Cardiovascular nurse education would be strengthened with a stronger focus upon content that reflects current health challenges faced in Europe. A broader view of cardiovascular disease to include stroke and peripheral vascular disease is recommended with greater emphasis on prevention, rehabilitation and the impact of health inequalities. Keywords Cardiovascular nursing, curriculum, post-registration nurse education programmes, survey, questionnaire Received: 22 April 2013; revised: 7 November 2013; accepted: 10 November 2013
1School
of Nursing, Midwifery, Social Work and Social Sciences, University of Salford, Manchester, UK 2Yvonne L. Munn Centre for Nursing Research, Massachusetts General Hosital, Boston MA, USA 3Centre for Health Services and Nursing Research, Kathlieke Universiteit Leuven, Belgium
4School
of Health Sciences, Jonkoping University, Sweden
Corresponding Author: Felicity Astin, School of Nursing, Midwifery & Social Work, Mary Seacole Building, (Room 1.64), University of Salford, Salford, M6 6PU, UK. Email: [email protected]
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Introduction Cardiovascular disease (CVD) including stroke, ischaemic heart disease (IHD) and heart failure (HF), represents a significant global health burden responsible for 47% of deaths in Europe alone.1 The greatest health challenge we face today is the epidemic of lifestyle-related conditions such as obesity and diabetes, combined with the ageing of the population. Although CVD mortality has fallen in most European countries an increase in cigarette smoking and physical inactivity, particularly amongst women and girls, is of concern.1 Non-communicable diseases will dominate with CVD and depression being the leading causes of healthy life years lost.2 An increasing number of people will live with one, or more, long-term conditions, making their care needs increasingly complex. The aging of the population means that the type of care required by people will be complex, continuous and community-based. The focus will require a paradigm shift from one of ‘cure’ to ‘care’. To tackle these health challenges health care workers, health care organisations and health care systems need to improve effective management of CVD within a long-term condition paradigm, with major efforts to be invested not only in state of the art medical therapy, but in primary and secondary prevention through collaborative partnerships with patients and their families. Nurses play a central role in cardiovascular (CV) care and optimum educational preparation and continuing education and professional development should guarantee that this, largest group of health care professionals, have the knowledge, skills and attitudes needed to contribute to reducing the burden of CVD .3 The Munich declaration: Nurses and midwives: A force for health published in 2000 marked an important turning point in the visibility of nurse and midwives in the European healthcare workforce.4 The document formally recognised the importance of nurses and midwives as a significant workforce with the capacity to make a considerable contribution to tackling the emergent public health challenges in Europe. Ministers of Health, the World Health Organisation (WHO) Regional Office for Europe and national nursing and midwifery associations unanimously supported the declaration. To fully realise the contribution of nurses it was acknowledged that initial and continuing education for nurses required strengthening. Moreover, legislative and regulatory frameworks needed to be in place to support comprehensive workforce planning and enable nurses to work as independent and interdependent professionals within their countries. In fact, the nature of the legislative and regulatory frameworks shapes educational provision and determines which clinical roles (e.g. advanced practice nurses’ roles) CV nurses are prepared for and their scope of practice within each role. A series of surveys was conducted to monitor and evaluate the implementation of the Munich declaration: findings from the 2009 survey indicated that reform of legislative frameworks for nursing had occurred in some
countries leading to an expanded scope of practice and responsibility.5 Moreover, the transition of nursing education from clinical settings to the higher education sector had also supported the establishment of self-regulatory bodies for nursing in some countries. Despite this progress, huge diversity in nursing preparation and practice remains largely unchanged across countries in the European region.6 This diversity is reflected in the educational preparation of nurses working in CV care across Europe. Preliminary evidence tells us that there is considerable variation in the setting in which educational provision takes place, whether it be university or non-university based. Moreover, there is considerable variety in the learning content and the scope of role expectations following basic nursing education throughout Europe.3 While there is an evolution towards a clearly articulated level of educational achievement for nurses from bachelor, master through to doctoral level (i.e. Bologna declaration7), as well as an investment in the streamlining of the educational structures and content within the European Union through the European Qualifications Framework,8 a wide spectrum of post-registration educational provision remains ranging from short programmes aimed at continuing education, to more advanced provision with accreditation to equip nurses for clinical specialist and advanced practice roles. Improved education, training and career development of nurses has been identified as a priority area to strengthen future nursing and midwifery services according to the WHO Nursing and midwifery services strategic directions, 2011–2015.9 Despite improved education being identified as a priority for nurses and midwives in Europe little is known about current post-registration programme provision. It is unclear how many programmes exist and the key features of the curricula and how they are evaluated. The aim of this study was to establish the number of CV education programmes that exist in Europe and to identify how they are structured, delivered and evaluated, the scope of content delivered and preferred assessment approaches.
Methods Definition For the purposes of this study a CV nursing programme was defined as the structured, provision of a CV education programme regardless of the type of programme, delivery methods used, and programme duration. Design. This descriptive study used a cross-sectional survey design with the administration of an electronic researcher-developed questionnaire. Sample and setting. A staged sampling approach was used to recruit participants. In the first stage, members of the Education Committee of the Council of Cardiovascular Nursing
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Table 1. Geographical distribution of countries involved in the survey. Country
Number of completed questionnaires by country (a)
United Kingdom/Ireland Sweden Czech Republic Austria, Iceland Greece, Poland Belgium, Bulgaria, Croatia, Cyprus, Finland, Germany, Lithuania, Portugal, Switzerland Total of participating countries=17
17 (1) 8 (3) 6 5 (1 Austria, 1 Iceland) 2 (1 Greece, 1 Poland) 9
aThe
41 (8)
number in brackets is of institutions reported not to have a course in which cardiovascular nursing was considered part of the curriculum.
and Allied Professional (CCNAP) identified nurse representatives from 43 European countries through existing national society networks. Nurse representatives, from 23 of the 43 European countries, were successfully identified and agreed to support recruitment. In the second stage, nurse representatives were asked to identify all CV nursing programmes in their country and to invite one person per CV nursing programme to complete the electronic questionnaire. Participants could respond if their organisation provided either a module/unit about CV nursing or a full programme that nurses could take after their initial training. Questionnaire development. A review of the literature identified no validated survey questionnaires developed to describe CV nurse education that we could adapt for our use. Accordingly the CCNAP Education Committee developed a 30-item questionnaire with two open and 28 closed questions. The survey questionnaire was informed by three key documents concerning educational provision for health professionals caring for people living with long-term conditions, and CV nurse education in particular. These were: the 2005 WHO report on basic competencies for the healthcare workforce in the 21st century in view of long-term conditions;10 the American Nurses Association and the American College of Cardiology Foundation, Cardiovascular nursing: Scope and standards of practice11; and the ‘European nurse training programme for clinical expertise in heart failure’ developed by the HF Association and CCNAP.12 The WHO report (2005) identifies patient-centred care, partnering, quality improvement, communication/information technology and a public health perspective as the basic competencies required by a 21st century healthcare workforce.10 The American Nurses Association and the American College of Cardiology Foundation Cardiovascular nursing: Scope and standards of practice11 document defines competencies beyond basic nursing education that link to both clinical practice and professional performance. Clinical practice competencies refer to assessment and management of CV conditions, education and counselling skills for comprehensive risk factor reduction, disease management and motivating patients to engage with a healthy lifestyle. Professional performance
competencies refer to research and evaluation skills, collaborative working, ethical practice and leadership. The European Society of Cardiology (ESC) ‘European nursing training programme for clinical expertise in heart failure’12 was also referred to as it referred to many of the aforementioned competencies and highlights the skills required to set up and run a heart failure programme. The survey questionnaire was developed and reviewed by the CCNAP Education Committee membership and two independent experts to establish face validity and completeness for the different countries in which data collection would take place. The tool was piloted on five expert nurse educators from Sweden (two), UK (two) and Switzerland (one). Minor amendments were made to reflect suggestions and a glossary of terms produced to promote equivalence in the understanding of terms across countries. The final version of the questionnaire addressed five areas: participant demographics and the reported need for a postregistration CV course (15 items); programme characteristics (10 items); teaching and learning methods (two items); assessment strategies (two items); and programme evaluation (one item). Items that defined the programme characteristics were divided into eight objectives. For each item the respondent was asked to confirm that specific topics were a part of their CV nursing programme as either ‘yes’ or ‘no’. The last item invited participants to comment on the value of a post-registration education programme developed by CCNAP. Appendix 1 in the Supplementary Material shows an abridged version of the questionnaire. Data collection procedures. The survey was conducted from December 2009–August 2011. The questionnaire and a covering letter explaining purpose, procedures, the need for only one survey per programme, and a web link to the survey was sent to the key contact persons who then further distributed these items among institutions and organisations that offered CV educational programmes.
Data analysis Data was transposed from the electronic questionnaire to esMaker, a web-based digital survey and analysis tool.13
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Astin et al. The items on the survey were individually analysed using descriptive statistics, i.e. frequencies and percentages of responses to each individual item.
Results Sample characteristics Of the 43 countries targeted to complete the survey, we identified key contact persons in 23 countries (57.5%). The key contact persons were identified either through the National Cardiology Society or known personal contacts of the CCNAP Education Committee membership. From these 23 European countries with contact persons, we had 17 countries that had 49 separate organisations that provided responses to the survey for individual postregistration programmes, providing a response rate at the country level of 41% (Table 1). Five organisations had more than one post-registration programme that met the inclusion criteria for our survey and therefore completed a survey for each. Participant demographics. The majority of the respondents who completed a survey, were female (74%) and were educated at the master (50%) or doctoral (39%) level. The role of the respondents in their respective organisations was lecturer/teacher (44%), senior lecturer (16%), head nurse (14%), project manager/director (10%), secretary/ administrator (8%), professor/associate professor (4%) or clinical lecturer (4%). Programme characteristics. Of the reported programmes, 68% were predominantly offered by a university, 20% by a hospital, 5% by a technical college and 5 (7%) by others such as district chambers, institutes for advanced training and national centre for nursing and health professions. Twenty-one programmes were reported (51%) to be part of an academic degree, both bachelor and master level, whilst 14 (34%) were certificates or diplomas offered by a variety of organisations. Four (7%) responses were from a part of a continuing education programme for post-registration nurses. Entry requirements were variable among programmes. For instance, 22 (54%) required clinical experience ranging from at least six months to five years, while 19 (46%) did not require any clinical experience. The European Credit Transfer System (ECTS) was used in 15 (37%) of the programmes. Course content. The next section describes findings about course content delivered across programmes. We present key findings in this article but all data can be accessed by readers in the accompanying electronic file (see Supplementary Material). In 27 (55%) of the programmes, CV nursing accounted for more than 50% of the programme content.
Objective 1: The scope of cardiovascular conditions taught to nurses. The CV conditions taught in more than 50% of nurse education programmes were cardiac arrhythmias, HF and IHD including angina and acute coronary syndrome, valvular heart disease, endocarditis, syncope and congenital heart disease. Less than half of programmes covered heart transplantation and peripheral vascular disease (PVD). Objective 2: The diagnosis of cardiovascular conditions. There was a range of content taught in nurse education programmes about diagnostics, both theory and skills. The process of recording and interpreting an electrocardiogram (ECG) was a key focus. Also biomarker interpretation, history taking and physical assessment were taught in more than half of the programmes. Assessment of heart and lung sounds and chest X-ray interpretation was taught in less than 50% of programmes. Objective 3: The impact of cardiovascular conditions on mortality and morbidity. In relation to the impact of CV conditions on mortality and morbidity rates, most programmes focused upon HF, IHD, valvular heart disease and arrhythmias. Content about congenital heart disease and PVD was less frequently addressed Objective 4: Supporting best practice in pharmacological treatments. CV medication guidelines were discussed in most of the programmes including detail about the mode of action and side effects of medications. Specific content on pharmacological treatment linked to cardiac interventions was most commonly reported for arrhythmia procedures, HF and IHD. Over half of the programmes addressed medication adherence with few programmes discussing valvular and congenital heart disease medications, or the impact of genetic variants on medication options. Objective 5: Nursing care and management of people with cardiovascular disease. Nursing care was most often discussed in relation to arrhythmia control procedures including device implantation and percutaneous coronary interventions and least often discussed in relation to congenital repairs. Content related to the management of healthy heart lifestyle behaviours was included in the majority of programmes (see Figure 1). Content related to sleep hygiene and complementary therapies was included in less than 50% of programmes. Objective 6: Using educational and behavioural theory to inform practice. More than 60% of the programmes identified theories linked to either student learning (for example adult learning theory) and/or behavioural theory (for example social cognition theory) to support practices such as patient education. More than half of the programmes taught students about ways to assess patients and families’ readiness
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Arrhythmia control procedures (Pacemaker, ICD) Percutaneous coronary interventions Coronary artery surgery Heart valve repairs and replacement Aortic repairs and replacement Heart transplantation Peripheral endovascular interventions Congenital repairs None 0
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Figure 1. Educational content taught about nursing care and management in post-registration nursing programmes (n=41). ICD: Implantable Cardiac Defibrillator.
Patient centred care Assessment of patient and family psychosocial needs Involving family and significant others Use of screening tools for anxiety and depression Human responses to CVD diagnosis and disease Identification of coping and crisis responses Cultural competence Accessing information in the community Therapeutic counselling techniques Identification of changes across the lifespan None 0
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Figure 2. Psychosocial activities taught in post-registration nursing programmes (n=41).
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Communication with patients and families Patient advocacy and patient centered care Defining the role of the members of the team Read and critique research for evidence-based care Use code of ethics for nursing Implement evidence-based clinical practice change Quality improvement inititiaves None 0
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Figure 3. Educational activities about multidisciplinary team building taught in post-registration nursing programmes (n=41).
to learn, barriers to learning, and how to define and evaluate learning outcomes. Almost one-fifth of the programmes reported that they did not teach any educational theory. Objective 7: Psychosocial assessment and support. Most programmes taught patient-centred care, psychosocial assessment and the principle of involvement of patients and family. Just over half of the surveyed programmes included content about screening for negative mood states (anxiety and depression)., Therapeutic counselling techniques, community, lifespan and cultural competences were available in less than 50% of programmes. See Figure 2. Objective 8: Promoting multidisciplinary team work. Content related to multidisciplinary team work were included in the majority of the programmes (Figure 3). The most frequently reported activities centred on effective communication skills, patient advocacy and the definition of the roles of multidisciplinary team members. Teaching and learning methods. The most widely used teaching and learning strategies in surveyed programmes were face-to-face lectures and seminars. Face-to-face lectures and seminars (when students present topics to other students followed by a discussion) were ranked as the most commonly reported educational delivery methods used in 97%, and 85%, of programmes respectively. The predominant framework used to assess the competency levels for the education programmes was most often based on a country-defined assessment (48%), or a skill
checklist (35%). Fifteen (37%) programmes were linked to ECTS with allocated points varying from 7.5–180. Other programmes had implemented alternative credit systems whilst others were unsure of what was offered for credit Assessment approaches. A variety of methods were used to assess knowledge and skill competency but examinations/ knowledge tests were the most frequently used techniques followed by essays and case studies. Other less commonly used assessment approaches were observed structured clinical assessment, portfolio, self assessment or peer review. Two programmes did not report an assessment approach for students. Course evaluation. Programme evaluation was most frequently conducted by students (n=39, 95%), educators (n=24, 58%), hospitals/universities (16, 39%), and external reviewers (n=18, 44%). All respondents reported an interest in the development of a post-registration programme in CV nursing should it be available.
Discussion Nurses are recognised as a significant workforce and have the potential to contribute to the vision of the ESC which is to reduce the burden of CVD. A snapshot of current educational provision gives a useful insight into the capability of the European nursing workforce. In 2009 less than half of the initial nurse education was provided by higher education institutions.5 This suggests that organisations providing
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vocational education were somewhat underrepresented in our sample as over 70% of participants were employed by a university. However, despite this higher than average representation from higher education institutions, only half of the programmes identified offered graduate or postgraduate level education. This finding highlights that a large proportion of nurse education continues to be delivered at a relatively low academic level when compared to other healthcare disciplines. When exploring the content of the curricula it was evident that the educational focus was based predominantly upon the management of patients with coronary heart disease (CHD) with less focus on the needs of patients with other forms of CV disease. The focus on CHD seems logical as it remains the leading cause of death across Europe, except in Greece, the former Yugoslav Republic of Macedonia, and Portugal where stroke takes the lead,1 but it would be advisable to take a wider view of the impact of CVD on health. Not all of the diagnostic procedures received the same attention in CV educational programmes. ECG interpretation was included by almost three-quarters of participating organisations whereas other aspects of physical assessment such as cardiac and respiratory auscultation and chest X-ray interpretation received less focus. This may reflect the extended scope of nursing practice evident in some countries compared to others. The assessed curricula included general information on pharmacological management of CV patients, yet only half of all programmes have integrated content of medication adherence which is a limitation given that nurses are in an excellent position to support patients with the management and adherence of prescribed medicines. This is particularly important given that medication adherence is a significant problem. Medicines will only work if they are taken and less than half of patients adhere to their recommended regime.14 Other aspects of self-management support and lifestyle change were better represented but the theories and interventions linked to patient education and behavioural change strategies were less well covered than the specific health behaviours. This suggests that there is a focus upon what lifestyle behaviours should be ‘changed’ rather than an emphasis on how interventions can be used to facilitate change. Nurses can make a significant contribution towards reducing the burden of CHD through their contribution, as a member of the multidisciplinary team, in the implementation of secondary prevention guidelines in clinical practice.15 To do this they need to be equipped with a basic understanding of educational and behavioural theory. The lack of emphasis on this content within the curriculum was surprising as competencies around effective communication, information provision and education of patients and families form the cornerstone of preventive cardiology in practice. These aspects of nursing curricula warrant attention. Self-management support to foster a healthy lifestyle for people diagnosed with CVD is an
essential competency for health care workers in the 21st century.10 The importance of patient-centred care was reflected in curricula, as was the assessment of psychosocial needs and family involvement. Other areas such as screening for negative mood states, culturally competent care, counselling skills and material describing normal and abnormal coping responses were less evident. Education about quality improvement initiatives was also fairly limited, meaning that an ability to demonstrate the provision of high quality care might be lacking. The way in which the content is delivered was typically through face-to-face lectures. The growth of educational technology will mean that more creative learning and teaching approaches will evolve and, where possible, methods that encourage nurses to engage with their learning and consider critical aspects of care should be considered. Likewise, most programmes used knowledge tests and examinations with other assessment methods, which are potentially more likely to assess understanding, somewhat underrepresented, e.g. supervisor’s report of clinical skill, portfolio and self-assessment. The WHO report argues that highly educated nurses are able to provide high quality care and ultimately reduce mortality (2009).3 Chan (2013) argues further that it is vital that we create and sustain a better-educated nursing workforce to meet the complex service needs of the future.16 If we are to achieve this aim it is necessary to increase the level of education of the nursing workforce whilst ensuring that learning and teaching methods produce competent, compassionate, knowledgeable, critical and reflective practitioners. In order to adopt a pan-European approach to the development of nurse education it may be necessary to extend the use of the ECTS points which is not yet common. A more widespread adoption of this initiative would support equivalence of awards across different institutions which would confer a range of benefits such as enhancing student mobility, aiding curriculum design and flexible routes to higher awards as well as supporting quality assurance processes.7,8 In summary, findings suggest that curricula for postregistration CV education are still largely driven by a medical model and characterised by traditional curricular structures and methods. Moreover, the emphasis on hospital care is stronger than on primary and community health care and competencies that would prepare nurses to care for the exponentially-growing group of patients that live with one or more chronic illnesses including CVD disease are given limited attention. A European core curriculum for post-registration CV education may be one approach towards harmonisation of nurse education across Europe but consensus must be reached about the characteristics of the core competencies and the feasibility of this approach across countries with diverse regulatory, educational and legislative frameworks.
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Astin et al. Whilst this study is one of the first published studies to assess CV nurse education in Europe it has several limitations which must be considered. There were considerable challenges linked to the sampling approach adopted. Given that no list of European postgraduate programmes exists, a staged sample approach was needed. A concerted effort was made to secure representation across all countries to minimise selection bias. We used key informants in the various European countries who subsequently identified and directed us to contacts who were knowledgeable about post-registration CV nurse education programmes in their respective countries. The failure to identify key informants in all European countries and/or the subsequent unsuccessful distribution of surveys within countries, partly because of language barriers as the survey was in English, resulted in a number of European countries not being included in the survey such as France, Italy, Spain, Norway, Romania, former Yugoslavia, Turkey and Hungary. The process was also time consuming which resulted in a delay between some data being collected and published. We acknowledge these limitations but, given the scarcity of information on this topic, we believe that our findings still warrant attention. We sought advice regarding common educational terms to support equivalence across different countries/languages but, despite this, some terms may not be accurately translated across educational settings.
Conclusion In conclusion, there is variability in the content, teaching, learning, assessment and evaluation methods in post-registration CV nurse education programmes in Europe. This reflects the variations in scope of nurse practice across different countries. CV nurse education would be strengthened with a stronger focus upon content that aligns more closely with current health challenges faced in Europe. A broader view of CVD to include stroke and PVD would be advantageous with an emphasis on prevention, rehabilitation and a greater awareness of the impact of health inequalities. As the population ages, teamworking across professions and specialties will be key as patients will be older and present with multiple co-morbidities requiring complex care and long-term support. An emphasis on interdisciplinary education will foster more effective teamwork across multidisciplinary teams and the use of advanced educational technology to deliver blended learning in a flexible way can afford many potential benefits.
Implications for practice • •
ducational provision for cardiovascular E nurses varies considerably across Europe. Access to graduate level education for nurses, the largest workforce in Europe, remains inconsistent.
• •
•
odernisation of nursing curricula should M include additional education on hypertension, stroke and peripheral vascular disease Additional education linked to lifestyle behaviour change is required with emphasis on prevention, rehabilitation and health inequalities. The use of educational technology may widen access to education for nurses.
Acknowledgements The authors would like to acknowledge the support of the ESC and national societies in supporting this study.
Conflicts of interest The authors declare that there are no conflicts of interest.
Funding This research was supported by funds from the European Society of Cardiology.
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